Advice please

[Pauline]

Hello. I was a member of this forum some nine years ago when my dear collie, Jaff, was DX with Addisons. Sadly he had to be pts as his Addisons was secondary to a pituitary tumour. He is still much missed.
Our present border collie, Jill, is now nearly 12. She was a four year old rescue when we acquired her in 2006.
Just this past three months she has experienced several episodes of diarrhoea. Her diet has not been changed. She is on an antistruvite diet as she tends to form crystals in her urine. No episodes of UTI for some time. We have had a blood test at the vets which revealed slightly lowered liver function and blood sugar but didn't seem to ring any alarm bells with the vets. She is recovering from a spell of loose faeces as I write this and we are awaiting the results on a poo sample tomorrow. Do you think it would be an idea to request another blood test and perhaps test for autoimmune disease. Having had such a dreadful time with Jaff the spectre of serious disease is gesticulating!!
My regards to you all and especially to Jan's pack if she is still around!!

[Jo CIMDA]

Hi and Welcome back Pauline, although I expect you'd rather not be here!

Is Jill well in other ways?  You are familiar with Addison's disease, and this has to be considered too.  Low glucose can occur with Addison's disease.  It is so difficult to know what is wrong when the symptoms and blood results are vague but I will copy some information about Addison's, to refresh your memory, and perhaps you can just bear it in mind for the future, that is assuming things don't improve with Jill - but obviously I hope they do. Jill already has one endocrine disease so it is possible she may get another, or another AI disease.  There is no one test for AI disease unfortunately you just have to monitor clinical signs and look at blood results until the evidence suggests a specific test.   Jan pops into the forum from time to time.
Jo

Primary Addison's Disease (Hypoadrenocorticism)
The diagnosis of primary Addison's disease is not complicated but some vets seem to have a reluctance even considering it in their differential diagnoses. It is often misdiagnosed as CRF (chronic renal failure), heart failure, gastrointestinal disease and even autoimmune haemolytic anaemia (AIHA) .  Many vets say "It won't be Addison's as we never see it". Unless your vet is looking for Addison's disease then it will not be diagnosed.  Addison's disease is known as 'The Great Pretender'. Many dogs are presented to their vet at least three times in the six months prior to diagnosis, and many are in an Addisonian crisis before it is identified.  Dogs have died waiting for the results of an ACTH test through lack of supportive care. 
The biggest hurdle can be to convince your vet to consider that it's possible that your dog may have Addison's disease and not to dismiss the notion without proving it and carrying out a thorough investigation and possibly an ACTH test. 
Even if your breed is known to be predisposed to Addison's disease, it is important not to become too obsessive and suspect that your dog has Addison's just because of a bout of diarrhoea or an episode of being a little off colour, but it is equally important to be aware of the telltale signs which could aid a diagnosis and maybe save your dog's life.

Points to Consider When Identifying Primary Addison's Disease:
Clinical signs:  Lethargy, depression, nervousness, weight loss, anorexia (no appetite), vomiting, weakness (particularly of the back legs), shaking or muscle tremors, limping, diarrhoea (with or without traces of blood), abdominal pain, dehydration, excessive thirst and urination, weak pulse, slow heart rate and abnormal heart rhythm, anaemia (pale gums) and collapse
Is your dog young / middle aged?
Over a period of time, has your dog experienced several of the typical symptoms and has he/she responded well to fluid therapy?
Has your young to middle aged dog been diagnosed with kidney disease?  Is he/she improving on the special treatment/diet provided by your vet? If the answer is no, then consider Addison's disease.
Do you have a dog whose breed is known to be genetically predisposed to Addison's disease?
Do you know of any relatives of your dog who may have been diagnosed with Addison's disease or kidney failure at a young age, or other autoimmune disease? Speak to your dog's breeder; they may be able to give you valuable information.
If You Suspect Addison's Disease
Have a Full Serum Biochemistry panel and a Complete Blood Count test done and ask your vet for a copy of the results for your own records.  Study the results yourself and note any abnormalities. If symptoms persist, have a further blood test done to see if there are any changes, but don't leave it too long in between (a week or less) as deterioration seems to quicken in the last stages.  Keep all laboratory reports for comparison in the future. Blood testing is never a waste of money (in the long term it can save you money), and it provides a 'bench mark' on which to compare further tests.  Addison's disease is progressive so a blood test is only valid at the time it was taken.  As the disease process progresses the values will change.
The Telltale Signs When Looking at Blood Test Results
Routine Laboratory Abnormalities  -  Haematology & Biochemistry
Sodium/Potassium Ratio
Greater than 90% of Primary Addisonian cases will have low sodium (Na) and high potassium (K) values, with a ratio of less than 27.  (Na:K)
Prior to diagnosis, Addisonian dogs often show a ratio of less than 23. The low ratio alone is very suggestive, but not diagnostic, of Addison's disease. Individual electrolyte concentrations can be more reliable.
As the disease progresses, the ratio will drop even further and the dog may collapse and become critically ill especially if stressed or excited.  Stress or excitement, to a dog with reduce adrenal function (even in one who has not exhibited typical, clinical signs of Addison's disease), can cause the dog to collapse or even die suddenly.
When comparing laboratory results look for the following as these will indicate Addison's disease.
INCREASED: 
High Potassium (K)
High Creatinine,
High Urea, (BUN – blood urea nitrogen; or SUN - serum urea nitrogen)
High Urea/creatinine ratio (Azotaemia)
Increased Eosinophils
Increased Lymphocytes
High Bilirubin -  in some cases
High Calcium (mild to moderate) – in some cases
ALT- ALP - AST (Mild to moderate increase of liver enzymes) – in some cases
DECREASED:
Low Sodium (Na)
Low Sodium/potassium ratio (K:Na ratio -  less than 27)
Note: Addisonian dogs often have a ratio of <23
Low Chloride  (80% of Addisonian dogs will have low chloride values)
Low Glucose – in some patients
Low Albumin (moderate to severe) – in some cases
Total white blood cell count (WBC) – in some cases
Red blood cell count (RBC or HCT)

Another possible difference between kidney disease and Addison's may be seen in the white blood cells (eg., neutrophils, eosinophils, lymphocytes). When a dog is ill (but does not have Addison's disease) he becomes stressed and this is often reflected in the white cells. The neutrophil numbers are expected to be high normal to increased, and the eosinophils and lymphocytes numbers are low normal to decreased. This is called 'stress leucogram' and is seen in both chronic and acute renal failure, but not in Addison's disease.

A dog with Addison's disease may show a different white cell reading than would be expected in such an ill dog.  In fact there may even be reverse of what would normally be expected, known as 'reverse stress leucogram'.
Reverse Stress Leucogram – may be seen in Addisonian dogs
Low normal numbers of neutrophils
Increased numbers lymphocytes and eosinophills
Electrocardiogram
•   Electrocardiogram  (ECG) is a very useful tool to detect various abnormalities of the heart resulting from high potassium levels in the blood.
Another very awkward differential is autoimmune haemolytic anaemia (AIHA).  I have known a few Beardies to be diagnosed with AIHA prior to being diagnosed with Addison's disease. The usual treatment for AIHA had been implemented but the dog's clinical signs did not improve, as expected, and clinical signs of Addison's disease, remained. 
If this happens you should check for signs of Addison's on previous blood test results to see if there were any undetected telltale results such as high potassium, low sodium.   These cases are further complicated because of the steroid treatment the dog will now be receiving for AIHA. A diagnostic ACTH test cannot be performed whilst a dog is on prednisolone, as it will interfere with the test results, so the dog's medication would have to be changed to dexamethasone for at least 2-3 days before an ACTH test is performed.
Prompt diagnosis and treatment, or supportive treatment, is crucial to the outcome of an Addisonian crisis and must be treated as a true emergency if the dog is to survive.
Life Saving Support
From BSAVA Manual of Small Animal Endocrinology, Chapter 19 – Endocrine Emergencies
"Whenever a diagnosis of Addisonian crisis is likely, treatment should be initiated without delay." 
"A tentative diagnosis of acute adrenocortical insufficiency can be made on the basis of the history and results of physical examination."
"Since death from acute adrenocortical insufficiency is usually attributed to vascular collapse and shock, rapid correction of hypovolaemia is the first priority in treating this condition."
1.   Restoring blood volume and
2.   Correcting imbalance of sodium and potassium levels and
3.   Treatment of life threatening cardiac arrhythmias
Within 1-2 hours, a saline only intravenous drip can restore correct hydration status, increase sodium levels and lower potassium levels which may be causing hyperkalaemic myocardial toxicity. In addition, other protocols may be used if myocardial toxicity is life threatening.
4.   Correct glucocorticoid deficiency
Dexamethasone is usually given as this has little or no effect on the measurement of endogenous cortisol concentrations and therefore does not interfere with the ACTH test.
Once diagnosis is achieved, the prognosis for an Addisonian dog is excellent. The dog should feel much better in a few days but it may take up to 6-8 weeks for the clinical signs and blood results to return to normal. Once stabilised the dogs will be maintained on Florinef (a mineralocorticoid with some glucocorticoid) only needing low replacement dose of prednisolone at times of stress (the 'supply and demand' facility for the fight/flight' response is no longer available to Addisonian dogs).  It might be prudent for the owner to anticipate stress such as a brewing thunderstorm and give a low, one off dose of prednisolone.  Life-long, daily hormone replacement therapy is essential. The oldest dog with Addison's that I have known was over 16 years old when she died, so getting that diagnosis is worth fighting for.

[Pauline]

Thanks Jo. We had further bloods taken today. Some results will be in tomorrow, those done at the vets. Some blood is apparently being sent away and will take 3 to 5 days for results to appear. Nothing back from the faeces sample yet. Jill is bright in herself although I have noticed she pants after exercise. I remember Jaff used to take a long time to recover from strenuous exercise before we obtained a diagnosis. The trouble is when you have only got a hammer everything looks like a nail!!!
The diarrhoea has abated. She is now back to normal if slightly hard faeces. Colitis is a tentative diagnosis and we are adding a small amount of oatbran to her diet to try to counter this.
I will keep in touch as soon as I have any results to hand. Thank you again.

[Pauline]

Update on Jill. She has been treated for campylobacter which showed in the sample. The antibiotics seem to have effected a complete cure and she is back to her normal self. Thank you.

[Jo CIMDA]

That's really great news Pauline. Thanks for the update and for sharing.  Good news is always welcome!

Jo